In March, we asked our readers to start sharing their stories of how the COVID-19 crisis is affecting them, both personally and professionally.
In our fifth installment, we share the journal of a Long Island RN who has not only cared for the sickest COVID-19 patients in the ICU, but also caught the virus. The story tells better than we could what health systems and workers on the front lines are going through, as well as that of the patients who depend on them.
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‘I knew I would get it’
Cepani Harjo, RN
Islip, New York
To whom it may concern:
I am an RN who works at a hospital in Nassau County on Long Island. I have written a journal since the inception of this new COVID era. I have been a critical nurse for 25 years and have a master’s from Stony Brook as an Adult Nurse Practitioner. I currently await starting with an electrophysiologist, but my career is on hold due to the current crisis.
I share my journal entries anonymously because I could be any nurse on the frontlines. I am without gender, age, race or nationality. I have changed the age and genders of my patients to avoid sharing their private medical information. I share them as some form of therapy for myself and hopefully for others. I am indebted to all those who support hospital workers in any position or in any manner: for every meal purchased, any notes of encouragement, every child’s picture scrawled with a crayon, any prayers, applause and all the love I’ve received from my friends and families.
I share this because I am profoundly proud to be part of a profession full of intelligent, strong, caring, sacrificing and devoted people who will risk all to care for others in need. This reads like a nightmare to me now. And that is what most of us health workers and staff are living now. They say truth is stranger than fiction. Two months ago, this would only be imagined as a movie script. Today it is an everyday reality.
This is my first day back after a two-week vacation. I am a critical care Float RN and can work on all the ICUs, Emergency Department, recovery rooms or telemetry units in a hospital in Long Island, New York. I have been a bedside nurse for nearly 25 years now, so I feel I have a pretty good vantage to view and experience the fields of medicine and nursing.
I hear we are starting to get a suspected handful of cases on the telemetry floors, and there are two critically ill in the Medical ICU. The two MICU patients who tested positive for COVID are on ventilators. They have multiple comorbidities and are older, in their 60s and 70s. Things seem under control thus far. Similar to a regular flu outbreak or the swine flu a few years back. I go back to my floor and resume my normal duties as an RN.
We have had our first COVID deaths. I am floated to another telemetry floor and not an ICU. In just three, days the number of COVID patients in the MICU has gone from two to 15 out of the 20 available beds. I do a fly-by of MICU, and the nurses are stressed and fearful, and are learning to live with the personal protective equipment on nearly all the time. Three of the telemetry units, approximately 30 beds each, are being converted to negative pressure rooms.
Total number of suspected cases is in the 50 to 60 range. The maintenance crew and carpenters have taken out the windows of the rooms and retro-fitted giant HEPA vacuum filters to pull and filter all the air in the room and divert it to the outside. Testing is more accessible and results come back in hours, not days or overnight, now. The news is not good. Most of the patients tested with symptoms of fever, cough, fatigue, muscle aches and some with diarrhea test positive for COVID 19.
My manager hands me a non-N95 mask and says, “This is your mask. Sign here,” and gives me a paper bag to put it in. I say thank you, and throw the flimsy mask and paper bag in the garbage on the way out of the office.
My first day caring for COVID patients. I am floated to a telemetry unit on the fourth floor, a 30 patient unit now wholly devoted to COVID patients. We have 17 positive patients on a unit which usually takes care of cardiac patients and I am assigned three COVID positive patients. All three have a cough, fever and shortness of breath, and are currently oxygen dependent with nasal cannulas delivering high-flow oxygen: a woman in her 80s, an obese patient with diabetes in his 60s and a double-amputee, blind, diabetic patient in his 50s who apparently was spitting and coughing on the nurses yesterday as they tried to gain IV access. Great.
The nurse assistants stay in the hallways at all costs and hand us a gown or fetch us linen if we need it. I have three glucose levels to check and the process of donning and doffing and sterilizing equipment is already tedious and burdensome. I scan the meds and prep the glucometer in the hallway, get dressed and then go into the belly of the beast.
I feel as though I’m swimming with my clothes on just trying to do my ordinary nursing tasks. The plastic gown has a suffocating feel to it and I start sweating beneath it within a few minutes. My glasses fog as the N95 diverts my humidified breaths upward. As the day progresses, humidity accumulates in the mask making it harder to draw breaths. A test that took a few minutes takes 15 now.
The 80-year-old female looks frightened as I enter. The HEPA filter drones loudly in the corner of the room. I have to shout through my mask to be heard as I ask her how she’s doing and if she feels short of breath. She is comfortable but afraid. I sense her loneliness and stroke her hair gently and then take her blood glucose. I listen to her rhonchorous and rattly lungs with a portable stethoscope and then leave her room to get her tray. I ask the nurse assistant to feed the patient and she shakes her head no and hands me the tray at arm’s length. The assistants have latched onto this new pervasive fear that surrounds every unit of the hospital now. My next patient awaits me so I leave the tray outside the room and it grows cold.
The next patient is in her 60s and is on high-flow oxygen attached to her nose that makes a whistling sound. I notice she gets short of breath merely by speaking one sentence as I assess and ask her questions. Her glucose is high and I forgot the insulin and syringe. Damn it. I doff the gown and gloves and the assistant wipes my face shield with a wipe. Thanks. She hands me the tray and asks if I can take the temp for her. Again, the recurrent theme of the assistant, “I don’t make enough to risk getting this.”
I share in the patient’s feeling of helplessness and loneliness. I am also on my own. I don my gown, mask, face shield and gloves, and go back in the room. She is lightheaded and short of breath, and nearly faints as I guide her to a reclining chair at her bedside. Again, I have to yell over the din of the filter as she asks for her phone and some tissues. She coughs constantly and tries to steer her cough away from me.
The coronavirus is spread in the droplets of the secretions of the infected hosts, so I do my best to avoid positioning myself between the powerful filter near the window and the patient.
I leave the room and I am off to my third patient, whom the outgoing RN called the a-hole who coughed and spit on us. His blood pressure is low, he is having massive amounts of diarrhea, in a pool of which he currently lies, and refuses an IV. I know this patient from a previous admission, call him by his first name and ask him if I can start an IV. He replies, “The other nurses tried eight times last night and they don’t know what the hell they’re doing.” I go out and futilely ask for help. The assistant hands me the linens and tries to hide her smirk. I go in and clean him unassisted. I set up his tray and he tells me he’s not eating that shit and to get him a Pepsi and a cheeseburger.
I remove my gear, walk down the hall to the break room, grab a donated bagel with cream cheese and go back to donning and entering the room. The patient has no teeth and says to just shove the pieces of bagel into his mouth and that he has gums of steel. He chomps on the pieces of soft bagel three or four times, swallows the chunk and asks for more. He is dehydrated from all the diarrhea so I encourage fluids between bites. Now I really remember this guy. He’s starting to laugh and smile toothless, and we both forget where we are for a moment. He tells me he’s probably going to die, but thanks for the bagel and soda anyway.
We have over 100 COVID patients. All the ICU’s are filled with ventilator patients now. One third of the hospital is full of COVID patients, and they have six floors dedicated to isolation patients. I get my first vent patient, a 70-year-old female who is not doing well. The ventilator becomes unattached twice while caring for her. The ventilator spews the humidified infected air of the infected patient briefly into my surrounding environment and I fear possible exposure.
After the palliative care MD notifies me of the plan to terminally extubate her tomorrow, I decide to dial back her care. She is sedated and comfortable but unaware of the decisions her husband and daughters have made for her. Her family wants to visit but they are not allowed under the new policy and are now banned from the hospital. The best we can do for now is hold a cell phone to the patient’s ear. “We love you so much. Hang in there. Miss you Mom, Gamma, honey.” I clean and turn her, fix her hair and turn to leave the room fighting off tears.
One of the nurses who now cavorts and talks and eats with everyone in close proximity had cared for a patient on a ventilator three days ago who was undiagnosed at the time. She was not wearing any PPE at the time and also fears she might have been exposed. Everyone in MICU socializes and commiserates as if nothing much has changed. There is no sense of social distancing as of yet. They still eat and drink coffee together in a small break room in the center of the unit, a virtual petri dish with table and chairs. The food and drink serve as the agar.
I stay clear of the other nurses and ancillaries, sensing that I am surrounded by vectors of COVID waiting opportunity to disseminate their viral loads. I order lunch out and eat by myself in the café downstairs. My theory is that hospital staff and their loved ones will serve as the second wave of the pandemic. And, unfortunately, this will turn out to be the case for a lot of the staff I’m working with, including myself.
Retrospectively I can’t keep track of where I’ve worked. The days begin to blur into one. I am exhausted. Nurses are doing overtime and are becoming frazzled. I am not sleeping well and have developed myalgia, but no cough or fever. I am 57 and I’ve already seen patients in their 40s die of this. I am an Episcopalian and listen to a mix of Christian music stations and news as I do my 45-minute commute. My church has closed its doors for the past two weeks, so there is no sanctuary or solace to be found there. Tears run down my face every day as I commute back and forth.
Three days off as I drive in for another shift. Neuro SICU. The shit hits the fan. Seven admissions. It is Saturday and the other critical care float who I’ve known for nearly 20 years and I have been sent to Neuro ICU to open a new section of the unit and receive COVID patients from the Emergency Department.
Tammy is a critical care float nurse also with nearly 30 years of experience. She is medium height, medium build, has purple/red dyed short cut hair. She is a tireless worker, has battle-tested experience and is perhaps one of the most sarcastic and stubborn people I’ve ever known. She is the perfect soldier to go into battle with. We arrive on the unit, meet the other nurse we are working with, Sue, a Neuro ICU nurse who has also been in the trenches. I cared for her father several times when he was in the hospital. The last time I saw her I was doing comfort care for dad. She is also an indomitable force at the bedside and has a heart of gold. Our team is assembled.
I grab a cup of coffee from the front section of the Neuro unit and learn that the ED is already on the phone ready to disseminate its first COVID patient. I don my gown, N95 mask, face shield and gloves and proceed to the back or ICU portion of the unit. I am back in the nightmare. The unit is horseshoe shaped with a front and back section. Our end of the unit, the back section, has a giant sucking HEPA filtering monster that pulls all the air from the front of the unit through the back of the unit.
We will receive our first patient in a bed that is directly in the alleyway of the COVID airflow created by this ceaselessly droning contraption. Oh yeah I’m going to get it.
The first patient is a 48-year-old COVID-positive, obese male who has a history of hypertension. He is on a non-rebreather mask with 70% high-flow oxygen. His breathing is labored and his fear is palpable as I put the electrocardiogram leads on his chest and hook him up to the monitor. Sue assists me, and Tammy starts the paperwork and works on getting his medications up to the floor. Pharmacy is understandably slow and often needs gentle prodding to get what we need.
His pulse oximetry registers in the high 70s and he is tachypneic, breathing rapidly, with a respiratory rate in the mid-30 range. The pulse oximeter measures the amount of saturated oxygen in a person’s blood. A normal finding would be approximately greater than 92% for most patients. I call for the respiratory therapist in the front section of the unit and she quickly emerges to help. A caring, competent RT is a critical care nurse’s best friend now and forever. She adjusts the oxygen mask and dials up the flow meter and the saturation climbs into the 80s.
I sense the patient is frightened, so I put my hand on his shoulder and ask if he needs anything. He groans that he hasn’t had anything to drink in nearly 24 hours. I think of the gospel parable, “Whatsoever you do for the least of these brothers and sisters you did for me.” The nurses in the ED are so overwhelmed that they have not the time to fetch a patient a sip of water. Neither do a lot of the new ED nurses have the aptitude to know that, although a patient has an NPO or nothing by mouth order, a patient can safely take sips of water then later be intubated without fear of aspiration.
I get him half a glass of ice water, pull his mask up and watch as he gladly gulps the water down like a cowboy in a dusty desert sucking from a canteen. He looks up, hands me the empty cup and says, “Thank you.” I quickly put his oxygen mask back on. When he finishes, he is seen by the pulmonary fellow, and I am instructed to prone the patient, or flip him on his stomach, because this seems to relieve shortness of breath. Sue and I assist the patient on his stomach, making sure he’s not lying on all the wires. His oxygen saturation climbs into the low 90s as the phone rings with the next ED transferee.
Tammy sits at the desk and handles the paperwork, the orders and admissions, and is still doing the worthless nursing care plans as if some lawyer might check them retrospectively when this is all over. The next patient arrives and we pull him from the stretcher to the bed. He is light, thank god, so I won’t need to take three Motrin, no Tylenol later today. (Ibuprofen is anecdotally linked to poorer outcomes with COVID patients. At least that’s the medical rumor for now). He is 70 years old, and his breathing is labored, in the 35-breath-per-minute range.
His non-rebreather whistles with high-flow oxygen and his pulse ox is in the low 90% range. OK for now, maybe he’ll be intubated later today. Sue and I hook up his EKG leads and clean him up. He is still in his pajamas from home and he is saturated from his mid-back to his toes in a pool of diarrhea. The nurse assistant hands up three packages of wipes, tossing them at the foot of the bed and walks away. I listen to the patient’s lungs with the yellow throw-away isolation stethoscopes and assess the patient. His breaths are shallow and his lung sounds diminished. He is not moving a lot of air. His back is curved like a humpback whale.
Kyphosis, my 10-dollar nurse practitioner term, comes to mind. It makes sense now. The patient has COVID, which attacks and infects his lungs. His underlying kyphosis creates a restrictive lung disease. His work of breathing is increased. His diaphragm, which usually operates effortlessly, begins to fatigue, and he must use accessory muscles, the intercostals and the muscles in his lower anterior neck. He is intubated one hour later after being assessed by the pulmonary fellow.
I explain what is going on to him, put my hand on his chest to comfort him and then administer as many sedatives as I can to knock him out. The anesthesiologist on call uses the Glide Scope to visualize the vocal cords and she slips the endotracheal tube into his lungs. The CO2 detector confirms placement as we listen bilaterally for breath sounds to make sure the tube is far enough in the carina. Bilateral breath sounds are confirmed. His oxygen saturation rises to 99% as we Ambu Bag him before he is placed on a ventilator. Thanks and goodbye from the anesthesiologist. She is gone like a vapor. He is clean, sedated, intubated and positioned comfortably in bed. The phone rings with the next patient from the ED.
Meanwhile, Tammy and Sue have taken a patient from the ED who is lying prone in the corner bed and coughing incessantly. Her oxygen saturation seems OK so she’ll have to work things out for herself for now.
Another patient arrives on a stretcher. Sue received a report on this patient, so I have no clue what we’re receiving. The patient is a male, is intubated and on a norepinephrine drip to maintain his blood pressure. Tammy notices the bag of norepinephrine is dry and makes a comment as the neophyte ED nurse races him off the stretcher and onto the bed. His heart rate is in the 120s and she tells us his blood pressure is great. We slide him across and the nurse starts pulling off the leads so she can grab the monitor and run. I warn her not to touch them until the patient is on our monitor. She pulls them off nonetheless and I race to get put our monitor on.
The patient’s pallor has turned grey as I hook up his EKG. His rhythm is bradycardic, slow, in the 40 beats-per-minute range as I feel for a pulse that is not there. I pull the code bell and start doing chest compressions on his chest. The attending physician, a cardiologist I recognize, swings around the corner and shouts to stop because the patient was coded three times in the ED. Thanks for the present.
I calmly ask the nurse assistant for a morgue pack. We clean the patient carefully and place him in a body bag. The nurse assistants grab a stretcher and a new admission is on his way. It is 3 p.m. now. I haven’t eaten or peed, but I hear there are wraps in the front break room. I grab a wrap, choke it down and redon my COVID garb for the next patient.
The ED gives a report. The next patient to arrive was a cardiac arrest resuscitated in the field, and also coded twice after arriving to the hospital. At least we get a heads-up this time. He is going for a CT scan before he arrives. A nurse from the front of the unit asks if I know how to do dialysis, and that her patient may have to start soon. I swing around the corner to assess the patient and give a quick perusal of his chart on the computer.
He is a 76-year-old with a history of dementia. His labs reveal multi-system organ failure. No, they won’t be in a rush to start dialysis on this fellow. I go out and grab a cup of coffee and gulp it down before re-entering the back of the unit. My patient has arrived and the shift is almost ending. We pull him across into the bed, hook up the monitor and I start to assess him. He is a 40-something male Hispanic. He has deep tan lines on his arms, and his hands are the hands of a laborer, rough and calloused. I listen to his lungs and do a neurological check on him. His eyes are fixed and dilated, and he lacks a cough, gag and corneal reflexes. Terrific they sent me the second dead man of my shift. He was probably resuscitated in the field after anoxic injury to his brain had already occurred. Sue and I clean him from head to toe, put a fresh gown on him, do mouth care and drape a fresh top sheet over him. Charting is out of the question as the new night crew comes in to relieve us.
At home it is the same routine. I drop my shoes outside in the back porch and wave to my two sons and wife in the living room from the kitchen. I make a beeline to the bathroom, drop my clothes on the floor and sterilize myself from head to toe. After I wrap the towel over my work clothes and walk straight to the basement and drop them in the washing machine and start it.
I walk upstairs, wash my hands again, pour myself a beer and say hello again to my people who are watching a movie in front of a warm fire. They slide to the other side of the couch as I sit with a thud, beyond exhausted. No hugs, no kisses for now. All this part of the new norm. I am a leper in my own home. I sleep alone on the couch in the living room, uncomfortably waiting for my next shift.
I work with Tammy again on another unit. Seven COVIDs between us. I’m too tired to write.
I awake at two in the morning with a splitting headache. My skin crawls and I have the chills. My throat is sore and I have developed a dry cough. Fear envelops me. I take deep breaths and pray the virus doesn’t invade my lungs. I go to the bathroom and diarrhea adds to my misery. I knew I would get it. I take 1,000 milligrams of Tylenol, gargle with Listerine and make my way back downstairs to the couch. I pass out.
I am exhausted, but the diarrhea and sore throat have left me. My head pounds, and Tylenol eases my pain. I call my primary doctor and friend’s office. He calls me right back and sends in a script for Zithromax to prevent pneumonia. I call in sick to the hospital. He orders a COVID test and it later comes up positive.
Nurses are cleared for work if they are seven days post initial symptoms or greater than three days without fever. I meet both criteria and feel relatively better so I report to work. They are so desperate for ICU nurses. When I report to the office to pick up my assignment the supervisors look at me as if they had seen a ghost. My favorite, Joan, says, “We really didn’t expect you.” Ten minutes later, I am in the cardiac cath lab recovery room, which has been converted to a COVID unit. I am assigned two patients on ventilators and oversee another nurse who has no ICU experience. I am back in the madness.
This journal was painful and difficult to write, but not as difficult as the actual experience. I just want to get it out there to be read. I tried to create a written documentary of what it was actually like. And to be honest it was and is a nightmare. I am glad I was exposed and recovered. It takes the pervasive fear in the hospital down a notch. One of my concerns with the story is that it seems rough on the nurse assistants. I love many of the nursing assistants and many of them are invaluable to patients, families and nurses. However, this was my exact account of what happened and honestly their behavior made the feeling of isolation and helplessness worse for me.
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